Tag Archive | "mental health"

A paper sign hung on the front doors to the Bronx Psychiatric Center. The doors are locked on Wednesdays while court is in session, it read.

Getting inside this courtroom isn’t easy. Two guards unlocked a series of doors which led to a small waiting room where people from a variety of nearby hospitals sat in silence. At the end of the room was one final door, with black paper taped over its window, obscuring what was on the other side.

Court was in session, former Bronx district attorney Robert Johnson was presiding.

There are a handful of courts like this one, in New York State: small, makeshift courtrooms in hospitals and health care institutions. There is no official name for these courts, they fall under the Mental Hygiene Law section of the Supreme Court. In theory, this court is open to the public. In practice, only those who have to be there are in attendance.

Every Wednesday, a judge hears cases under the Mental Hygiene Law Article 9. Simply put, the court presides over cases in which the hospital wants to keep mental health patients hospitalized against their will, or require patients to comply with treatment if they are being discharged.

On this Wednesday, Kimberly Tate-Brown, was the attorney assigned by the state to represent the respondents–the people with mental illness. Mr. L, (only the initials of the respondents are being used to respect their privacy) was one of her clients. On the other side of the aisle was the hospital’s lawyer.

Mr. L, who is 45 but looks older, shuffled across the small courtroom to his seat. He had a large growth on the back of his head, the remains of an injury he refused to treat. Mr. L had refused court mandated medical treatment, known as Assisted Outpatient Treatment (AOT). The hospital was fighting to force him, legally, to take his medication.

“I want a fair hearing,” said Johnson. The hospital has a lawyer, he reminded Mr. L and spoke of Tate-Brown’s extensive experience as an attorney. “I think it’s to your benefit.”

Reluctantly, Mr. L agreed to let Tate-Brown be his co-counsel.

The proceedings in these cases are simple. The doctor testifies, the patient testifies. Occasionally a family member will testify.

Mr. L’s doctor testified his patient had chronic schizophrenia and delusions the hospital was trying to poison him.

Mr. L tried to interrupt. He mumbled half-hearted objections, shook his head and looked down. Tate-Brown tried to keep Mr. L calm. Her job is part attorney, part care worker. She’s been working as a mental health lawyer for 12 years. Originally from New Hampshire, her background was as a nurse and then as a psychiatric nurse practitioner. She went to law school and learned about these specialized legal services.

“This is perfect, it’s a combination of my nursing background, my psych background,” she said. “Immediately, I knew it was something I wanted to do.”

There is a high risk of non-compliance in the Bronx. Dr Lizica Troneci, Chair of the Department of Psychiatry at St. Barnabas Hospital, said that out of her patients, maybe 30% have family support. The rest do not. Some live in shelters. There’s a significant problem in the Bronx of revolving door hospitalizations and the non-compliance will often make the illness worse, Troneci said.

When Mr. L testified, he rambled. He said he was not mentally ill and complained that his civil rights were being violated. He waved a photocopy of his driver license, which he believed, demonstrated his ability to be responsible for himself.

Mr. L was adamant the judge see the copy of his driver license. Tate-Brown passed the paper to Johnson and he looked it over. She said later that she knew it would make no difference. Since it would not hurt his case, she respected Mr. L’s wish.

The courtroom was informal. Only the judge and lawyers wore suits. There were eight seats on each side of the gallery and many of those present looked at their phones. One hospital lawyer played a game on his phone while he waited for his hearing to begin.

Verdicts weren’t read in front of the respondent. Mr. L was escorted out of the room. Johnson stated that Mr. L was mentally ill and would be a danger to himself. The hospital had succeeded in its petition and Mr. L was forced by law to comply with treatment and take his medication. If he fails to comply, he could be brought back to the hospital and end up in the same court. The court could at that point, force him to stay in the hospital.

The success rate of hospitals in New York City and State for AOTs petitioned, is 95% since it began in 1999, according to the Office of Mental Health. In other words, the court almost always rules in the hospital’s favor when mandating treatment.

It’s difficult when clients are not well, but don’t want treatment, Tate-Brown said. But she has to respect their wishes when she represents them, she said.

“I’m not making the decision,” she said. They are entitled to due process. If Mr. L wants to show his driver license then he has a right to do that, she said.

Much of Tate-Brown’s job is ensuring people like Mr. L get a fair trial and that the hospital sufficiently makes its case.

Before the case goes to court Tate-Brown talks with doctors to determine whether it is necessary to go the legal route. Doctors, she said, fear lawsuits. They don’t want to be the ones who put someone dangerous back on the streets. Sometimes she can persuade the doctor that court isn’t necessary. But the law mandates that anyone suffering from mental illness who has been hospitalized at least twice within 36 months must go through Article 9 of the Mental Hygiene Law. Sometimes, the hospital is getting ready to let the patient go when the patient petitions for a release.

It wasn’t always this way. In 1999, Andrew Goldstein, a mentally ill man, pushed a young woman, Kendra Webdale in front of an oncoming subway train in Manhattan, killing her. He had been hospitalized multiple times and criticism grew around the failure of the mental health system to recognize Goldstein as a threat. Up until this point, if a person was hospitalized for mental illness and medical non-compliance, they would be discharged without much accountability.

Webdale’s death prompted the introduction of Kendra’s Law, otherwise known as Assisted Outpatient Treatment. Almost all states now have AOT. More than 16,000 people in New York City have been given court orders for their treatment since 1999.

The law was criticized from the beginning. Many claimed forcing a person to stay in hospital or take medication was a breach of civil rights. History has not been kind to the medical world when people have been forced into treatment in error. The ice-pick lobotomies and electroshock therapy that were in practice in the U.S. and western Europe well into the 20th century as a cure for homosexuality, as an extreme example, seem barbaric through today’s lens. But the dilemma is clear: how does the court balance the rights of the individual and protect society at large?

That’s why Tate-Brown’s job is critical, she said.

She also represented Mr. Br, 32, who was diagnosed with schizoaffective disorder.

Mr. Br sat quietly as he listened to his doctor’s testimony.

The doctor claimed Mr. Br had been difficult, describing his “hyper-religious behavior.” He was “screaming about God without making sense,” the doctor said.

Mr. Br had been abusing PCP. But when he was discharged, he was “pleasant and apologized for what he did,” according to the doctor.

Mr. Br’s mother also testified. She said her son cared for her in the evenings. She wasn’t aware of the conditions under which he had been hospitalized.

“We will manage at home,” she said when asked if she would make sure Mr. Br takes his medication.

When Mr. Br testified, he was calm.

“I’m not depressed,” he said. “I’m fine.”

The medication makes him “flip,” he said. Mr. Br explained that he had been hospitalized because, while on the way to a job interview, he stopped to do push ups in front of a church.

“I wasn’t jumping up and down.”

If a person is acting strangely due to drug abuse, the hospital doesn’t have the right to hold them on the basis of mental illness. But once someone is labelled mentally ill, it’s often difficult for them to prove their sanity. The first judge is often the person on the street who calls the ambulance or police, the second is the doctor who evaluates the condition, and third is the court judge.

In Tate-Brown’s opinion, the judges on retention cases, when the hospital is arguing to force the respondent to stay in hospital, get it wrong about a third of the time. It is easy to imagine that the doctor’s testimony would be given more weight than the respondent’s, whose testimony is prone to be met with skepticism, she said.

There was an instance, Tate-Brown remembered, when a woman claimed her son was hiding her medication. She was not believed. It turned out to be true.

In Mr. Br’s case, the hospital did not make a convincing argument there was a threat of “imminent harm,” (a criteria for these cases). The hospital had not argued sufficiently that his behavior was caused by mental illness. Mr. Br was granted release.

A court mandated treatment will not work well if the individual is reluctant, Tate-Brown said.

“If the person doesn’t agree with it and it’s imposed upon them,” she said, “what good is it going to do?”

The court actually has the discretion to begin with a voluntary agreement, then if the patient fails to comply with that, they can resort to court mandated treatment.

Tate-Brown said it’s more typical in New York City for the court order to come first.

“To me it’s ass backwards going for a court order first and then stepping people down to a voluntary if they’re willing to agree.”

Harvey Rosenthal, Executive Director for the New York Association of Psychiatric Rehabilitation Services, agreed that forcing someone who is mentally ill to comply with treatment, isn’t always the answer.

If it’s just the same treatment that hasn’t worked, simply forcing them won’t make it better, Rosenthal said.

“Coercion has no magic to it, ” he said.

More than a civil rights issue, Rosenthal believes the issue is the right to the best care and a court order has become a default. He believes in building trust. If something doesn’t work send another care worker, try something different. Often, he said, it’s a matter of paying attention to a lack of food, money or representation. While there may be 16,217 AOT court orders in New York City since 1999, he pointed out, there have been 19,261 cases of voluntary alternatives, instances in which the patient signs a voluntary agreement.

“Would coercion make the difference?” he asked. It’s an empty promise.

Another respondent, Mr. Bl, knew treatment was right for him and had no intention of fighting the AOT in court. He had been hospitalized four times since the beginning of the year, but most were voluntary hospitalizations. Because the court does not distinguish between self hospitalizations and other other kinds, he has to go to court simply in order to agree to something he was already willing to do.

Mr. Bl goes to the hospital for rest sometimes, he said. The judge asked where he would stay if he were let out of the hospital. He said he couldn’t go home because he was fighting an eviction. He was waiting for his benefits to come through before he could move home. Once he’s discharged from the hospital, he said, he’ll stay in a shelter.

One Monday in October, therapist Shlomit Levy was called to a classroom at I.S. 313, a middle school on Webster Avenue in the Bronx where she has worked for the last four years. A student was causing disruptions, storming out of class.

The clinician from a nearby mental health clinic, Astor at Highbridge, took the student aside for a two-hour therapy session. The student was able to return to class with the help of Levy, but not for long. Half an hour later, she had lost control again.

In her emergency session, Levy discovered the student’s family was not cooperating with her therapy. If Levy had been able to see the child earlier, the crisis might not have happened.

But last year, the state pulled its Clinic Plus funding that required I.S. 313 to have parents fill out mental health assessments for their children. Now that the program is gone, the clinician has no information about which children may need help.

The result is that Levy now in October has only one new student patient, at a time when she usually has at least 10. “I’m missing a lot of information,” she said.

Shlomit Levy, a clinician for Astor at Highbridge in I.S. 313, is seeing far fewer children ever since the clinic lost its state funding. (VALENITNE PASQUESOONE/The Bronx Ink)

Levy’s referral numbers from schools in no way reflects the area’s need. The only mental health outpatient clinic for children and teenagers in the Highbridge section of the Bronx, Astor at Highbridge serves more than 400 clients ages 2 to 21. Patients are seen in its Shakespeare Avenue clinic and inside six local public schools. Its future is uncertain in a community where 52 percent of the population has already received mental health treatment or counseling. In 2006, mental illness hospitalization rates were significantly higher in Highbridge and Morissania than in the rest of the Bronx and New York City.

Levy said the children she sees are suffering from trauma and anxiety among other issues. Some of them have lost a family member to gang violence, or have been sexually abused. Others have parents who are either arrested, incarcerated, or deported. Levy has had patients who lost all contact with their deported parent. Undocumented, these students can’t leave the country to go visit them.

“All these children have such challenging life environments,” Levy said. The therapist is convinced five clinicians like her are needed in I.S. 313. “And we would all be very busy.

The end of Clinic Plus not only curtailed services for needy children, but also created a greater financial problem for the clinic. It came at a time when Astor at Highbridge is being squeezed by yet another cut in state funding. Since 2010, New York State has gradually reduced its direct support for Astor’s two outpatient clinics in the Bronx by 25 percent per year. The same day Levy was called to P.S. 313, the clinic received word that a third 25 percent reduction would go into effect next year, totaling 75 percent lost revenue in three years. The cuts mean clinicians are under pressure to increase the number of clients who bring in Medicaid or private insurance money.

Astor at Highbridge opened the satellite clinics in schools in 2007. The clinic now has six clinicians who work in neighboring schools. Astor was keeping these services afloat after Clinic Plus money ended, yet times are difficult.

“A couple of my schools want more clinicians,” said Zory Wentt, program director at the Astor at Highbridge clinic. “Do we need it? Yes. Are we going to get it? No. We don’t have enough funding for that.”

Wentt has worked a Astor at Highbridge since it opened seven years ago. It remains the only mental health clinic in the area. It was difficult at first to convince residents to overcome their fears and seek therapy, she said. A strong stigma attached to mental health needs was a barrier.

“A lot of children need mental health services. Yet they have never received it,” Wentt said.

A book Levy and other clinicians use to help students in schools. (VALENTINE PASQUESOONE/The Bronx Ink)

At the clinic, therapists see children with conditions ranging from attention deficit-hyperactivity or oppositional defiant disorders to those with bipolar or suicidal symptoms. Violence in the area spills over into their clinic. Trauma and post-traumatic stress disorders are common illnesses.

“We had a little girl whose father was shot right in front of her,” Wentt said. “We have a lot of death cases, along with children being placed in foster care or suffering from sexual trauma.”

In a neighborhood where 35 percent of residents live below the poverty line, according to a study by Queens College, lack of resources can become a triggering factor when it comes to mental illness. The majority of the clinic’s patients are low-income, Hispanic and African-American residents. Eighty-five percent of them are on Medicaid and 5 percent have no insurance. Only 10 percent can afford a private health insurance. Revenue from these insurances is now Astor’s only chance to survive financially.

“Funding is a challenge, we’re constantly out there seeking private funding,” said Sonia Barnes-Moorhead, the executive vice president of the Children’s Foundation of Astor. Astor Services for Children and Families operates 12 sites in the Bronx, including two outpatient clinics. Clinicians have had to provide the same services in a way that could decrease costs.

Astor at Highbridge has been affected by what appears to be a national trend: increasing and larger cuts to mental health state funding.

According to the National Alliance on Mental Illness, more than $1.8 billion has been cut from mental health state budgets in the U.S. from 2009 to 2011. At the same time, one in 10 American children have serious mental health conditions like depression or stress disorder. New York is the second state where cuts are the largest, after California. It cut $204.9 billion in its mental health budget between 2009 and 2012.

Three years ago, the New York State announced it would reduce its Comprehensive Outpatient Program Services (COPS) funding by 25 percent each year, until no funding is left. The state increased Medicaid rates to keep outpatient clinics afloat, but centers like Astor at Highbridge face direct consequences. The COPS funding represented half of the clinic budget, about $1.5 million.

Services at the clinic have been reorganized, and the workload has become barely manageable for some therapists. In 2009, a clinician had about 20 cases in total. Now, their caseloads vary between 50 and 55 people.

“We’ve had to work harder, we’ve instituted a business-like model in mental health services,” Wentt said.

The mental health clinic started to launch open access sessions four days a week for three hours in order to build their client base.

Things can easily become hectic during open access time. Children cry when their parents meet with the therapist, leaving them in the waiting area. Crises can erupt when children fight. A parent advocate and front desk receptionists are available to care for them, but they can often feel overwhelmed.

“With open access, no one is allowed to have a free moment when people come in,” Wentt said.

Zory Wentt has worked at the Astor at Highbridge clinic since 2005. (VALENTINE PASQUESOONE/The Bronx Ink)

With Astor’s limited staff, new clients are often left waiting. On Oct. 1, Nilza Martinez, a 26-year-old resident of Highbridge took advantage of open access hours. She and her 6-year-old child waited for more than an hour, only to be given an appointment two weeks away. No Spanish-speaking clinician was available that Monday.

Her son’s pediatrician at the Bronx-Lebanon Hospital Center had referred her to the Astor clinic. Her son, she said, was showing extreme anxiety about sleeping, and being left alone.

Clinicians said their heavy caseloads prevent them from being entirely available during open access services. Every week, they need to have an average of 25 billable hours of direct contact with their clients to keep the clinic alive. Some of them say they have to schedule appointments almost every hour to maintain this requirement.

“There is a lot of pressure since we have a lot of paperwork and accountability on top of the work you do in sessions with the children and families you’re working with,” said Audrey Williamson, a 26-year-old social work intern working as a full clinician at the clinic since September. She works 21 hours a week at Astor at Highbridge, besides her classes at Columbia University School of Social Work. She is required to see her clients for at least 10 billable hours.

“Yet I think the pressure of helping and assisting children and their families is much bigger,” Williamson said. “You have lives in your hands for the most part.”

A Bronx cop involved in the ticket-fixing probe has been admitted to a psychiatric ward, after he tried to kill himself after testifying in the case, reports the New York Daily News.

Robert McGree, 62, tried to kill himself Sept. 14 in the subway. On Wednesday, cops took McGree into hospital for a suicide watch after he briefly went missing from his home in Riverdale and family members expressed concerns about his depression.

Several Bronx cops have been embroiled in a ticket-fixing scandal, as well as leaking information about the probe. A grand jury is convening this week to determine the charges against the officers.